further problem is that the so-called ‘symptoms’ are not examples of bodily dysfunction, such as pain, rashes and so on, but consist of a ragbag of social judgements about people’s thoughts, feelings and behaviour. For example, someone – usually a woman – diagnosed with ‘borderline personality disorder’ has been assessed as displaying ‘inappropriate, intense anger’ and ‘a pattern of unstable personal relationships.’ But we know that women who are so labelled very often have a history of abuse, which may make their so-called ‘symptoms’ entirely understandable.
Similarly, there is growing evidence that the hostile voices said to be a symptom of ‘schizophrenia’ may reflect earlier unprocessed traumas, such as bullying or domestic violence. And at the less severe end of the spectrum, the desperation and hopelessness that might be diagnosed as ‘depression’ is known to occur more often in personal and social contexts that give people very good reasons to be miserable. These histories are routinely obscured and unaddressed within a system that re-interprets them as evidence of medical illness or disorder.
In essence, then, a diagnosis turns ‘people with problems’ into ‘patients with illnesses’. Reactions to receiving a diagnosis vary, and some people say that it offered welcome relief from guilt and isolation. For others, though, it constitutes the first step in a lifelong career as psychiatric patient, with everything that is implied – long-term use of psychiatric drugs, stigma, and social exclusion. Some have vividly described the profound disjunction in their sense of identity as this new version of reality is imposed on them: ‘I walked into (the psychiatrist’s office) as Don and walked out a schizophrenic … I remember feeling afraid, demoralised, evil.’
Psychiatric diagnosis turns ‘people with problems’ into ‘patients with illnesses’.
How, then, do we proceed, if we want to accept the reality of people’s distress and yet dispute the validity of the medical explanations that are offered? This model has taken hold so strongly that it can seem bizarre to question it. And yet we have a mountain of research to confirm that all kinds of social and relationship adversities massively increase the likelihood of experiencing all varieties of mental distress. This includes poverty, unemployment, emotional neglect, physical and sexual abuse, domestic violence, bullying, and so on, as well as more subtle difficulties such as feeling criticised, undermined, invalidated and excluded.
At a wider level it has been demonstrated beyond dispute that we all suffer from living in societies that are unjust and economically unequal – ‘If Britain became as equal as the four most equal societies […] mental illness might be more than halved’ (Wilkinson & Pickett). Similarly, psychologists have described how whole societies may be affected by so-called ‘austerity ailments’ of humiliation and shame; fear and distrust; instability and insecurity; isolation and loneliness; and feeling trapped and powerless.
This perspective does not give us the neat explanations or the hope of simple cures that are offered by a diagnosis and a corresponding pill. It implies that we need very different solutions, at every level from individual to societal. One possible starting point is the core skill of all clinical psychologists, known as ‘formulation’ (Johnstone & Dallos). This is the process of making sense of a person’s difficulties in